Protection of healthcare information from damage, loss, and unauthorized alteration is also known as

security

Which technology eliminates lost orders and problems with legibility?

Computerized physician/provider order entry

The paper-based health record format that organizes all forms in chronological order is known as

the integrated health record

The health record documents services provided by allied health professionals and a patient's family

False. The health record documents the care provided by healthcare professionals.

An individual's right to control access to his or her personal information is known as

privacy

When all required data elements are included in the health record, the quality characteristic is met for...

data comprehensiveness

Patient care managers are individuals users of health records

True

Fuctions of the Health Record

*planning and managing care*evaluating the adequacy and appropriateness of care*substantiating reimbursement claims*protecting the legal interests of both patient and healthcare provider

Clinical data elements documented in the acute care health record

*clinical observations*discharge information*medical history

Functions of the discharge summary

*ensuring the continuity of future care*providing information to support the activities of the medical staff review committee*providing concise information that can be used to answer information requests

What way can the patient's consent to undergo treatment be expressed?

*by submission to treatment*by written agreement*by verbal agreement

These are considered clinical data

*progress notes*physician orders*admission diagnosis

not name of insurance company

Which federal law resulted in the new privacy regulations for healthcare organizations?

The Health Insurance Portability and Accountability Act

Which report includes names of the surgeon and assistants, date, duration and description of the procedure and any specimens removed?

operative report

An example of an advanced directive

living will

Materials documented in an emergency care record

patient's instructions at dischargetime and means of the patient's arrivalemergency care administered before arrival at the facility